Enter up to 6 people who were in the vehicle at the time of the accident.

First and Last Name

Is this person a AAA Member? (Yes/No)

Reimbursable Emergency Expense*

Select one expense resulting from an accident, fire, theft of vehicle you are claiming.

Replacement car rental

Local lodging and meals

Commercial transportation to destination

Incurred Expense*

Enter the total amount you are claiming for the above checked item.

Accident Report

Upload the police/accident report, repair bill and all itemized receipts*

You may upload up to 6 documents under 2MB.

Drop files here or

Accepted file types: jpg, pdf, png.

Police Department to which the accident was reported*

Vehicle Make and Model*

License plate number*

Name of person driving at the time of the accident*

FirstLast

Was the driver also the registered owner of the vehicle?*

Yes

Now

If not, enter the name of the registered owner*

Date of the accident*

Time of the accident*

:HH

MM

Describe how the accident happened*

Location of Accident

Name of Street or Highway*

City*

State*

Number of miles away from home*

Enroute to*

Enroute from

Vehicle Damage Report

Describe the damage to the vehicle*

Name of garage, shop or station where the vehicle was repaired*

Address of repair provider

Street AddressAddress Line 2CityStateZIP Code

Cost of repairs*

Terms & Conditions*

I understand that reimbursement will be paid within specified limitations based on paid receits enclosed and will not exceed $200.00 per accident ($500.00 for AAA Plus coverage) for the first 72 hours, or until the destination is reached, or the car is repaired, whichever occurs first. Benefits are claimed only for AAA Oregon/Idaho member and accompanying spouse.